Wisconsin Department of Health Services

Time Elapsed: 0 minutes Time Remaining: 0 minutes Total Time: 0 minutes Anonymous Login Code: Save this code, which is required to update your response at a later time.   Page 1 of 1     Wisconsin Public Psychiatry Network Teleconference        Division of Mental Health and Substance Abuse Services F-21283 (09/2008)       Please enter information on the presentation for which you have participated.       Note: * indicates that the item is required     1. Date of Presentation:*   mm/dd/yyyy     2. Presentation Topic:*       3. Presenter:*         Please submit one form for each participant for each teleconference. In order to receive credit you will need to have the survey completed WITHIN TWO WEEKS of the teleconference. Please note that we would like each registrant to register for each teleconference with the Wisline online registration at http://www.uwex.edu/ics/wlreg/wlwelcome.cfm     4. Respondent's Last Name:*       5. Respondent's First Name:*       6. Respondent's Position:       7. Respondent's Gender:   Female   Male       8. Respondent's Ethnicity:   Asian   Black   Hispanic   Native American   White   Other, please specify          9. Respondent's Agency:       10. Address:* (Mailing Street Address or P.O. Box)       11. City:*       12. State:*       13. Zip Code:*       14. Respondent's Email Address:*         For items 15 - 19, please check the answer that most closely reflects your assessment of this presentation.     15. Importance of Topic*   Excellent   Good   Fair   Poor       16. Quality of Presentation*   Excellent   Good   Fair   Poor       17. Quality of Materials*   Excellent   Good   Fair   Poor   Not Applicable       18. I expect this training to benefit consumers.*   Strongly Agree   Agree   Disagree   Strongly Disagree       19. I expect to use the information gained from this training.*   Strongly Agree   Agree   Disagree   Strongly Disagree   Not Applicable       20. Additional Comments: (What Was Most Useful or Were Areas that Need Improvement)       21. Suggestions for Future Teleconferences:   Topics:   Speakers:         Contact Information: Sola Millard, LCSW UW-Madison Department of Psychiatry In support of the Division of Mental Health and Substance Abuse Services Bureau of Prevention, Treatment, and Recovery 1 W. Wilson, Box 7851 Madison, WI 53707-7851 Telephone:(608)261-6743, FAX:(608)267-7793 Email: sola.millard@wisconsin.gov       Please click on the DONE button when you have completed the evaluation. This will electronically submit your evaluation. Certificates of Attendance are mailed in January (July-December teleconferences) and July (January-June teleconferences). Teleconference Website: http://www.dhs.wisconsin.gov/MH_BCMH/confandtraining/

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